This week I will be giving a talk on office infection control to the podiatric assistants at the American Podiatric Medical Association (APMA) National Meeting in Boston. I believe this is an area that does not receive enough attention since it is far from “sexy” or cutting edge, but is still important.
Last year, I sat in on discussions by the Clinical Practices Committee of the APMA in an attempt to come up with some guidelines for disinfection and sterilization of instruments for the podiatric physician. This document is available online for APMA members by searching the term “disinfection” in the Members Section at www.apma.org  . The guidelines incorporate information from the Centers for Disease Control and Prevention (CDC) document “Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008.”1 Much of the CDC document is not directly applicable to daily office practice. Accordingly, there was a need for the specialized guidelines.
In the APMA document, we approached podiatric instrumentation much the same way as the dentists classify their instruments. We break down instrumentation into the following three categories.
Critical instruments. These are any objects that enter sterile tissue or the vascular system, and therefore must be sterile because any contamination could transmit disease. These instruments would include any instrument used in a surgical procedure. Sterilize these instruments.
Semi-critical instruments. These instruments contact non-intact skin. Examples would include tissue nippers or curettes clinicians use in debridement of an ulceration or incision, and drainage of an abscess. These devices require high-level disinfection.
Non-critical instruments. These come in contact with intact skin or nails. Virtually no risk has been documented for transmission of infection through non-critical instruments. Examples would include nail nipper and burrs or handles clinicians use for debridement of keratotic lesions. One can use low-level disinfection although intermediate level disinfection is recommended.
Sterilization is the complete elimination of all vegetative bacteria, fungi and viruses along with any bacterial spores. One can achieve this through a number of methods including the most commonly used steam/autoclave with a recommended minimum exposure of 30 minutes at 121° C. Other techniques include gas sterilization with ethylene oxide for moisture or pressure sensitive devices. In the current document, based on FDA findings in dental offices, glass bead sterilization is not recommended.
Disinfection falls into the following three “levels.”
High-level disinfection. This is the complete elimination of all microorganisms on an instrument except for a small number of spores. It usually occurs with a chemical such as glutaraldehyde.
Intermediate level disinfection. This destroys all vegetative bacteria, viruses and fungi but not bacterial spores. This can occur via with phenolic compounds, iodophor, alcohol or chlorine.
Low-level disinfection. This destroys all vegetative bacteria (except tuburcule bacilli) viruses and fungi but no spores.
Finally, the APMA Guidelines discuss the need for various levels of disinfection with debridement procedures. Debridement falls into categories of manual, mechanical and dust extraction.
Manual. One should clean instruments such as nippers and curettes that clinicians use in the manual debridement of nails with intermediate level disinfectants. Do not reuse scalpel blades and treat their handles as non-critical instruments.
Mechanical. Thoroughly clean burrs of any nail debris/dust and treat them with intermediate level disinfectants as non-critical instruments.
Dust exposure precautions. The APMA recommends a dust extraction system or other safeguards to avoid exposure. This may fall more under an OSHA recommendation than an infection control practice but I feel it is a critically overlooked precaution in many podiatric offices (as evidenced by the response I receive when I talk to podiatric assistants about this issue).
This was just a superficial review of a complex topic but it is one of importance to all practices. These guidelines are practical and quite “doable.”
I remember sitting in on a lecture on office infection control at a Washington State Podiatric Medical Association meeting a few years ago. This talk, given by an infection control nurse working with a local county’s health department, basically required every single surface of the treatment room to be covered in disposable plastic drapes before each and every patient, and thoroughly wiped down between patients. It was far from practical and would have bankrupted the practice.
If we do not follow basic infection control procedures as outlined in this APMA document, who knows what agencies will be telling us what to do next.
1. Available at http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf  .
Editor’s note: This blog was originally published at http://www.leinfections.com/infections/infection-control-and-instrument-...  and has been adapted with permission from Warren Joseph, DPM, FIDSA, and Data Trace Publishing Company. For more information about the Handbook of Lower Extremity Infections, visit www.leinfections.com/  .